Where was the communication breakdown in the Harold shipman enquiry?

Answer 1

When things go wrong in the National Health Service, an inquiry is often set up to find how what happened and what can be learnt. Since the 1970s inquiries have been resorted to increasingly often to investigate service failures. Such inquiries take various forms. I don't think there was a breakdown in the communication in Harold Shipman's enquiry. We can see in the inquiry: How the Inquiry was established, the Inquiry team, interested Parties accredited by the Inquiry, chronology of the Shipman case, ministerial statements, terms of Reference, opening Statement by Dame Janet Smith DBE, Chairman of the Inquiry, and transcripts of Procedural Meetings.

The recommendations are contained in the Fourth Report of the Shipman Inquiry, 'The regulation of controlled drugs in the community'. Harold Shipman was "addicted to murder", having abused his position of trust in the community to kill his patients, typically through a lethal injection of diamorphine. He enriched himself either by persuading patients to include him in the will, or by forging the necessary documents.